Healthcare Provider Details

I. General information

NPI: 1912902107
Provider Name (Legal Business Name): CHARLES WILLIAM PETTUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 HIGHWAY 54 W STE 2200
FAYETTEVILLE GA
30214-2114
US

IV. Provider business mailing address

20 FRANCIS WAY SUITE 101
SHARPSBURG GA
30277
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-0051
  • Fax: 770-716-0087
Mailing address:
  • Phone: 770-253-0611
  • Fax: 770-502-0521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number033675
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: